Indications for surgery to remove the uterus and uterus withappendages, contraindications, preparation, types of operations

TOогда врач выносит вердикт: «Матку необходимо удалить», многие
women see it as a sentence. There is no doubt that surgery is
forcible intervention in the human body, and removal of the uterus
you can say personal. But not everything is so scary, and many
patients after surgical intervention begin
new life, both literally and figuratively.

Indications that determine the operation

Hysterectomy is scientifically called uterus removal,
never carried out just like that, “for prophylaxis”. TOак удаление
uterus with appendages, and without them is carried out strictly according to indications.
And if the doctor / doctors insist on hysteroscopy, then
should agree with their opinion. A woman is recommended surgical
intervention in case of:

  • malignant tumor of the uterus
  • malignant lesion of the cervix
  • symptomatic uterine myoma
  • uterine fibroid size greater than 12 weeks gestation
  • rapid growth of fibroids (the size of the uterus increases in 12 months
    at 4 weeks of pregnancy)
  • necrosis of uterine fibroids
  • uterine submucosa
  • menorrhagia complicated by anemia
  • Grade 3-4 adenomyosis
  • sex change
  • chronic pain syndrome in the pelvis
  • prolapse of the uterus
  • endometrial diseases without improvement from conservative therapy
    and healing scraping

Is it necessary?

The doctor insists on hysterectomy, and the patient categorically
against what to do?

  • First, you should consult with another doctor,
    third, tenth. It is possible that the attending physician is sincere.
    is mistaken.
  • Secondly, consider other options that replace
    hysterectomy, in particular these include conservative
    myomectomy and uterine artery embolization.
  • Third, consider all positive and negative
    стороны грядущей hysterectomy.

TOонсервативная миомэктомия хороша тем, что позволяет сохранить
organ intended by nature for carrying a child and therefore
performed for women of childbearing age. TO отрицательным моментам
include the possibility of growth of myoma nodes and practically
lifelong (at least until menopause)
dispensary observation at the gynecologist. TOому проводится
conservative myomectomy:

  • the presence of myoma node on the leg (i.e. its location behind
    outside the uterus) or subserous nodes
  • miscarriage (2 or more cases of spontaneous
    interruptions) and sterility (in the case of excluding other causes and
    available at least 1 node, whose dimensions exceed 4 cm)
  • menstrual disorders, accompanied by bleeding
    and anemization of the patient
  • large sizes of myoma nodes (exceed 10 cm)
  • dysfunction of the bladder and / or intestines due to compression
    knot myomas

Surgery uterine artery embolization

It is considered an innovative technology, although it began
apply back in the 70s of the 20th century. The essence of embolization is
catheterization of the femoral artery, then the catheter reaches the uterine
arteries (under the control of radiography), and then the branch points
from her vessels that supply blood to the nodes of fibroids.

The introduction of special drugs through the catheter creates a block in
small vessels going to myomatous nodes and breaks
blood circulation in them. Uterine artery embolization is
an excellent alternative to surgery to remove uterine fibroids, since
helps to stop the growth of nodes, and even reduce them or
disappearance.

This operation is performed in the presence of growing uterine fibroids to 20
weeks, but if there are no diseases of the ovaries and cervix, and
women diagnosed with infertility due to
myoma TOроме того, эмболизация маточных артерий показана при
uterine bleeding, life-threatening. However, there are
situations where hysterectomy for fibroids cannot be replaced
something else:

  • uterine submucosa
  • large sizes of uterine fibroids
  • combination of fibroids with internal endometriosis and tumors
    ovary
  • persistent bleeding that lead to anemia
  • growing tumor

The positive side of the operation to remove the uterus

Before deciding on an operation to remove the uterus with appendages or
without, you should weigh all the pros and cons. TO положительным сторонам
hysterectomy include:

  • lack of menstruation and problems with them
  • no need for contraception
  • the disappearance of pain and bleeding, which greatly complicated
    a life
  • protection against uterine cancer (no organ – no problem)
  • weight reduction, waist constriction

TO отрицательным моментам относятся

  • psycho-emotional disorders
  • cicatrix
  • the duration of pain after surgery is 3 – 6 – 12
    months
  • observance of sexual rest lasting 1.5 – 2
    months
  • earlier menopause
  • risk of osteoporosis and heart disease for 5 years
    earlier

Withмер из практики: У меня была одна пациентка
of childbearing age, which endlessly aborted my abortion (see
consequences and complications of abortion). With uterine cancer is registered she
It has been a few years. And after the next interruption
pregnancy situation very complicated: in the uterus was located
interstitial node that grew and practically blocked
clearance in the area of ​​the isthmus. Scraped with great difficulty
and risk. I put the patient before the fact that she needed
amputation of the uterus, which is done in the regional hospital. After
hospitalization she calls: “I am being offered a conservative
myomectomy, and you said that you need supravaginal amputation of the uterus
how to be? ”Of course, I, as a doctor, should advocate
the preservation of the organ, but as the attending physician I was totally against it.
Who and how abortions will this woman do next, she will
keep up the good work? But the doctors of the regional hospital decided
keep the patient’s reproductive function and leave the uterus,
cutting knots. Yes, well done, yes, clever. But the question is: if a woman
would like to give birth, would she have done a dozen abortions? Well, not
she needs a womb. And by the way, she already had a child, about 15 years old. To my
Fortunately, she moved to another city and disappeared from my field
view.

Anesthesia for hysterectomy

Removal of the uterus is performed under general anesthesia. Apply 2
method of anesthesia:

  • intravenous anesthesia (with intubation of the trachea and the absence
    spontaneous breathing)
  • and regional anesthesia (spinal and epidural
    anesthesia).

Intravenous anesthesia is most commonly used for abdominal surgery.
(when the uterus is removed by cutting the anterior abdominal wall).
The advantages of such anesthesia are in the patient’s deep sleep,
no pain and good patient control.

With laparoscopic surgery to remove the uterus and vaginal
hysterectomy preference is given to regional anesthesia, which
carried out in two ways. Spinal anesthesia
causes rapid pain relief of the lower torso of the patient, and
maximum relaxation of the abdominal muscles during epidural anesthesia
pain relief occurs after some time, but this method
allows you to treat pain after surgery. Sick in
the time of the regional anesthesia in the mind, but does not feel
the pains.

Of course, when choosing anesthesia are guided by the state
patient, the urgency of the situation, the estimated volume
intervention and its duration. The operation time is different, and
may be from 40 minutes to 3 hours.

Types of hysterectomy

Removal of the uterus is not just the elimination of a diseased organ, so
how often hysterectomy is combined with excision of others
anatomical structures. Depending on the volume
Hysterectomy surgery is divided into:

  • subtotal – uterus amputation (the cervix is ​​preserved)
  • total – surgery to remove the cervix and the uterus itself
    (extirpation)
  • hysterosalpignoovarectomy or panhysterectomy – removal
    uterus and ovaries with appendages, cervix
  • radical – extirpation of the uterus with appendages, upper third
    vagina, the pelvic fiber that surrounds the uterus and
    regional lymph nodes

Depending on how access is performed, they are distinguished
The following types of removal of the uterus:

  • laparotomic hysterectomy (the uterus is removed through
    longitudinal or transverse section of the abdominal wall)
  • removal of the uterus laparoscopically (several punctures, from 2 to 4,
    in the abdominal wall through which the laparoscope is inserted and
    instruments)
  • vaginal hysterectomy – access to the affected organ
    carried through the vagina
  • vaginal removal of the uterus with laparoscopic
    assistance

A radical hysterectomy operation is performed in the case of
malignant lesion of the uterus with the transition to the neck or
malignant process of the cervix. Total hysterectomy
necessary for significant sizes of uterine fibroids, common
endometriosis, combined diseases (tumors) of the uterus and cervix, and
also to women after 45. In other cases, amputation is performed.
uterus. Remove appendages or not – often this issue is solved in
operation time when the ovaries and tubes are visible to the naked
by eye.

How will be accessed, for the most part depends
from the operating physician. But sometimes women are asked to do it themselves.
choice.

The advantages of abdominal hysterectomy are low cost,
reliability, low risk of intraoperative complications, the possibility
perform it in almost any gynecological department. TO
disadvantages include: a large scar on the abdomen, duration
hospital stay (10 days), long
recovery period (4-6 weeks).

TO достоинствам лапароскопической гистерэктомии относятся:
statement after 5 days, short recovery period (2 – 4 weeks),
no cosmetic effect (no scar), low risk
the formation of adhesions in the abdomen, and, consequently, the smaller
probability of adhesive disease with severe pain. TO
disadvantages include: high cost, the probability of transition to
laparotomy, performed only in large hospitals (medical
centers and institutes).

Vaginal hysterectomy is better tolerated, there are no scars on
stomach, recovery period is shorter, 3-4 weeks, almost
no pain after surgery. TO минусам относятся: сложная
performance technique and high risk of intraoperative complications.

Contraindications for hysterectomy

Removal of uterus, ovaries, tubes just like all others
surgical operations have contraindications. In the list of common
contraindications include any acute and chronic infectious
processes in the acute stage, inflammatory diseases of organs
sexual sphere (vagina, cervix, appendages and uterus), heavy
chronic extragenital diseases (cardiovascular
pathology, pathology of the bronchopulmonary system, blood diseases and
others), pregnancy.

Laparoscopic hysterectomy cannot be performed with very
significant size of the uterus or ovarian tumors, with
множественных спайках в брюшной полости, в случае выпадения uterus.
Vaginal removal of the uterus is contraindicated in adhesive disease,
after cesarean section, with a large uterine myoma, with
inflammation of the vagina and cervix, as well as suspected cancer
uterus / cervix or if available.

Preparation for surgery

Before a hysterectomy, you must be examined,
which includes:

  • clinical urine and blood tests
  • blood clotting
  • biochemical blood test (cholesterol, total protein, glucose,
    AST, ALT, creatinine and other indicators)
  • ЭTOГ, консультация терапевта
  • smear from the vagina, urethra and cervix on the microflora (see
    white blood cells in a smear)
  • research on genital infections by PCR (chlamydia,
    ureaplasmas, HPV, herpes infection and others)
  • cytology smear from the cervix and cervical canal
  • colposcopy (for cervical pathology)
  • blood per group and Rh factor (in the department there should be no
    less than 1 liter of blood of the required group)
  • histological examination of the endometrium (after diagnostic
    scraping)
  • radiography of the lungs
  • dental visit and sanitation of carious teeth
  • Gynecological ultrasound

In some cases (with significant uterine fibroids or
severe endometriosis) to the patient to prepare for surgery
hormone treatment is prescribed for a period of 3 months or more
aim to stabilize the growth of nodes and the progression of the disease.

With varicose disease of the lower extremities for several months
appropriate treatment is prescribed in case the patient
takes antiplatelet agents, they are canceled 10 days before surgery.

The day before the operation, the patient is assigned a table number 1 (liquid and
rubbed food) evening cleansing enema, which in the morning
repeat. On the day of the operation, the intake of food and water is prohibited. After
of the premedication, the patient is delivered to the operating room.
(a urinary catheter is inserted in advance and the legs are bandaged with elastic
bandages).

TOак проводится гистерэктомия

TOак проходит операция удаления матки интересует всех, без
exceptions, patients. To dispel doubts and clarify
If you have any questions, talk to the surgeon the day before.
interventions.

After того, как женщину транспортировали в операционную, ее
placed on the operating table and fix the limbs.

  • In the case of vaginal hysterectomy, the patient’s legs are bent in
    knee and hip joints (as on a gynecological chair)
    and divorced to the side.
  • For laparotomic or laparoscopic access, anterior
    the abdominal wall is treated with antiseptic solutions, the patient in
    this time is under general anesthesia or regional
    anesthesia.

A layer-by-section abdominal wall incision is made, then estimated.
organ situation in the pelvis (size of the uterus, localization of nodes,
condition of appendages, with suspected malignant process
the circulatory fiber and adjacent organs are examined for
metastasis).

The final decision on the volume of the operation is made by surgeons.
after opening the abdomen. The uterus and / or appendages are cut off,
hemostasis and closure of the abdominal wall in layers. With
necessary, the abdominal cavity is drained (risk of bleeding,
peritonitis and other circumstances). If it was planned in advance
extirpation of the uterus, the vagina is reorganized on the operating table
antiseptic solutions and plugged with a sterile cloth.

With лапароскопическом удалении матки после обработки
antiseptics of the anterior abdominal wall in it are produced 3 (in
average) small incision length of 1.5 – 2 cm. One is entered
laparoscope with microvideo camera
organs on a large monitor (the operating
surgeon), and through the remaining 2 air is forced into the abdominal cavity and
special laparoscopic surgical instruments are introduced.
The course of the operation in the future is no different from abdominal
hysterectomy.

Vaginal hysterectomy is the removal of the uterus through the vagina.
After асептической обработки влагалища в него вводятся зеркало и
lift, and a cut is made in the upper third. In technical
the plan, this operation is more complex and requires a certain
mastery of the surgeon.

Withмер из практики: TOогда я впервые делала
supravaginal (laparotomic) amputation of the uterus my first shock
experienced, when she cut her stomach and saw the uterus, all in nodes. So and
I wanted to quit everything and leave, as in a joke: “still nothing
it turns out. “Basically, amputation uterus is a simple operation but
pitfalls lurking in the capture of the uterine arteries (they go along
the ribs to the sides of the uterus, but with the eye, they are certainly not visible). On uterine
arteries in place of their intended course are superimposed by 2 clips with
each side (away from each other). After чего матка
it is cut off, arterial stumps are ligated, the stump of the uterus is sutured with
by stitching appendages, the anterior abdominal wall is peritonized
sewn tightly. And so after the uterus was cut off, with
one side gushing blood and instantly flooded the entire stomach. it
means that the artery was not intercepted. But the surgeon (very experienced)
he did not lose his head and blindly intercepted the pulsating vessel (with his
parties happened). it был мой второй шок во время operations.
The further course of the operation without complications, the postoperative period
flowed smoothly. The patient was discharged with thanks for the operation and
for not having to go to the regional hospital.

Duration and cost of the operation

Important question: “The operation to remove the uterus: how much it costs”
also rises before a woman. The specific cost of the operation is difficult
to name

  • First, it is determined by the region in which it lives
    future patient, level of hospital equipment, qualifications of a doctor,
    suture material that is used in the operation, volume
    interventions and conditions of stay in the postoperative
    period.
  • Secondly, the price depends on the surgical access and the type
    operations.
  • For example, uterine artery embolization costs about 100,000
    rubles,
  • Laparoscopic extirpation or amputation of the uterus from 16,000 to
    90,000
  • removal of the uterus by the vaginal route in the range of 20,000 – 80,000
    rubles.
  • A hysterectomy performed by laparotomy should be
    free in the hospital at the place of residence or in the regional center, but
    private clinics conduct such interventions for money. Price
    колеблется от 9 000 до 70 000 rubles.

Removal of the uterus: how long the operation lasts

Definitely can not answer this question. Duration
hysterectomy depends, again, on the volume of the operation, its complexity,
complications during surgery and access.

  • On average, laparotomic hysterectomy lasts from 40 minutes to
    2.5 hours
  • laparoscopic lasts 2.5 – 3.5 hours,
  • vaginal 2 – 2.5 hours.

After операции

Bed rest after removal of the uterus and / or appendages
abdominal by 24 hours. At the end
the first day a woman is allowed to get up and carefully
move. Early physical activity activates
intestinal peristalsis and prevents the development of paresis. Because
pain after surgery, especially on the first day, expressed,
analgesics are prescribed.

Prophylactic administration of antibiotics is indicated.
anticoagulants. The stitches are removed for 8 days, and the discharge is carried out
after 8 – 10 days. After лапароскопии больная встает уже через 5 –
6 hours, she is allowed to go home after 3 to 5 days. Elastic bandaging
legs must be on the first day after surgery,
but preferably for the entire early postoperative period. Before
table No. 1a is assigned to the patient’s independent chair (wiped and
liquid food), and after a bowel movement, a general diet.

Possible early complications:

  • internal bleeding of varying intensity
  • bleeding from postoperative suture and formation
    hematoma
  • injury to adjacent organs (unsung damage
    bowel and bladder during surgery)
  • thrombophlebitis of the lower extremities
  • suture suppuration
  • vaginal prolapse
  • infection of the urethra and bladder
    (consequence of prolonged catheterization)
  • peritonitis (inflammation of the peritoneum)
  • thromboembolism

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